Austin Frakt at the Upshot is highlighting a very intriguing study about hospital productivity. The upshot of that start is that hospitals are getting way more productive than they previously were, and that is a huge deal for public policy, health policy, and population health.
Can hospitals provide better care for less money? The assumption that they can is baked into the Affordable Care Act…. The study, published in Health Affairs by John Romley, Dana Goldman and Neeraj Sood, found that hospitals’ productivity has grown more rapidly in recent years than in prior ones….
According to the analysis, productivity fell for heart attack and heart failure patients between 2002 and 2005, after which it began to rise. For hospital care for all three conditions examined — heart attacks, heart failure and pneumonia — productivity growth accelerated after 2007. By 2011 it was more than 14 percent over the level it had been in 2002.
The source of the broadest optimism from the study: Hospital productivity increased in the most recent years faster than that of the overall economy.
This is a single study that is extremely interesting and intriguing but it needs follow-up work and it needs other studies using different methods/assumptions to validate the result, but this is intriguing. It also jibes with what insurers are reporting from the claims perspectives as costs are roughly growing at nominal economic growth rates.
In my opinion, there are plenty of spaces for hospitals to get even more productive without harming patients. We just need to stop being stupid before we have to start getting smart. Earlier in the month, Aaron Caroll noted that we as a society overtreat patients with methods that increase mortality risk:
I saw this study a few weeks ago on blood pressure treatment for nursing home residents, and I almost ignored it. There are so many like it. But it’s just ridiculous that this kind of stuff continues, and that we can’t seem to do anything about it….
We know that in many people, high blood pressure is bad. We therefore try and do things to lower it. But then we go ahead and decide that if lowering blood pressure in some people is good, it must be good for everyone. In frail, elderly people, however, there’s no evidence for this—and there may be evidence that lowering blood pressure is a bad idea. But that runs counter to what we’ve always been told, so many ignore it….What the study found, to no one’s real surprise, is that the people on two or more blood pressure medications who had a systolic blood pressure of less than 130 mm Hg had a significantly higher all-cause mortality.
There are lots of corners of medicine where it is practiced as a folk art with strong heuristics that are extensions of either prior training or stretches from the evidence base. In the case that Dr. Caroll is commenting on, not giving most old people blood pressure medication saves money on both prescription costs and crisis stabilization costs while improving the patients’ quality and length of life. That should be a net win where not being stupid is a massive productivity enhancement.
Jim
One of the little things that drives me up a wall is having a nurse take my blood pressure with an electronic cuff, then manually inputting the results into a computer. Or worse yet, writing the results on his/her hand, for later transcription into a computer down the hall. Why can’t blood pressure cuffs talk directly to computers? The technology has been available for years.
Richard Mayhew
@Jim: Because that blood pressure cuff is using a different protocol than the Electronic Medical Record system…. and yes, this is an area of fairly low value work that should be made obsolete
Amir Khalid
How does this increased productivity affect the hospital business? Does it, for instance, wind up eating into profits by reducing the number of revenue-earning opportunities?
Baud
Ergo, “tort reform.”
I'mNotSureWhoIWantToBeYet
Anecdata follows:
Falling is a big problem in the elderly, and when old people fall they often injure themselves, sometimes very seriously.
One of the causes of falls is people feeling faint.
What can make people faint? Having too-low blood pressure.
It really shouldn’t be surprising that lowering BP in the elderly isn’t a universal good.
I’m convinced that part of the problem with medicine in general (and with political reporting, also too) is the thinking that numbers are objective and that the numbers we can easily measure are the numbers that are meaningful. In politics, polls and fundraising numbers can be fudged – they’re not “objective”. Similarly, body temperature and BP numbers are just a tiny piece of the puzzle of what our bodies are doing and why. Studies of a few dozen or a few thousand people should not be taken as applying to everyone without compelling evidence.
I know there are lots of political operatives and medical researchers who get this stuff right. Unfortunately, their work is often swamped by those who twist things for clicks or perceived advantages…
Cheers,
Scott.
Riggsveda
One of the cheapest fixes to get and keep people well while in hospitals is simply getting the hardheaded docs and nurses to just wash their damned hands between patients. Staff becomes impatient and imperious about this, but it can save more lives and prevent more needless disease than almost any other step. In one hospital, docs were cavalier about new policies requiring this, until the administrator had to order cameras put into the sink areas. Sometimes, contemplating this and the huge amount of iatrogenic illness rampant across hospitals, I feel as if we are back in the days of Lister trying to convince hospitals to spray carbolic acid into operating rooms.
Shakezula
One of the sections in MACRA calls for (another) look at gainsharing, I know the basic hurdle is the fear that greed will have some sort of negative impact on patient care (hence OIG’s case-by-case approach). Do you think that’s one area where it could help hospital (and physician) productivity or is the difficulty in creating a workable policy a sign that it just can’t be done in a non-stupid manner?
satby
I originally went to nursing school instead of college, back in the days when hospitals had their own diploma nursing schools. One of my first assignments was to select a drug and really investigate all the uses, contraindications, and potential side effects. I chose Tylenol, and what I learned from research on my paper has had me avoid Tylenol for 50 years whenever I had an alternative medication. But the Tylenol company handed out samples to doctors and hospitals heavily, while emphasizing how much “safer” it was supposed to be (as long as we didn’t mention the liver). Medical professionals, all of whom had access to the same PDR I did, fell in line, and Tylenol became the drug of choice for decades, resulting in about 55k overdoses requiring hospitalization and causing liver failure in thousands of people per year.
This was known in 1975, the official warnings started to come out in 2009.
I’m always a sceptic when it comes to pharmaceutical companies.
Edited to add: and the ability of pharmaceutical companies to ever broaden the definition of illness to what used to be normal.
Emily68
Sorry for the nit pick, but it jibes, not jives.
Steeplejack
@Richard Mayhew:
That should be “jibes with,” not “jives.”
Wag
@satby:
As a physician I share your concerns about pharmaceuticals companies and their marketing techniques. One of the best days I have had in my 25 years in practice was the day my practice closed the doors to pharmaceutical reps.
Emily68
@Riggsveda: There was a story in the New Yorker a few years ago about the company that invented the hand sanitizer, Purell. Inventing it was easy. The hard part was convincing medical people to use it instead of hand-washing. But people ended up figuring out that the skin on their hands felt much better after repeated gelling than after repeated washing. Plus it was quicker than hand-washing. You could get a squirt of gel and be on your way to the next patient with no tedious standing around at the sink.
Central Planning
@Richard Mayhew:
Can you please explain productivity growth with respect to heart attacks, heart failures, and pneumonia? What variables/measurements go into determining that growth? Is it something like time to patient stabilization, time to treatment, less people dying, etc?
Thanks!
a hip hop artist from Idaho (fka Bella Q)
@Wag: I likewise share your (plural) concerns. But was one of the worst days in your practice the day when pharma was permitted to directly advertise to consumers?
satby
@Wag: I wish more doctors took your approach! Thank you on behalf of your lucky patients!
satby
@a hip hop artist from Idaho (fka Bella Q): OMIGOD, yeah. That’s got to be a hassle.
And so many people refuse to make the lifestyle changes that would keep them healthy. They want to still chow down on fast food and take a magic pill to counteract the ill effects.
Steeplejack (phone)
@Richard Mayhew:
Half fixed. You still need the “with.”
rikyrah
thanks for the info!
Richard Mayhew
@Emily68: @Steeplejack (phone): Thank you both :)
Richard Mayhew
@Central Planning: Length of stay in hospitals, 30 day and 1 year survival rates, costs
gelfling545
@satby:
I’ve been wondering about this. Apparently now if your bp is 121/80 you have “pre-hypertension” instead of pretty good bp. Without meds my bp runs 120-125/80-85; with them it runs about 106/65 & I feel like crap. My usual range used to be considered fine when I went to the doctor but now it’s a big, prescription-requiring deal. I have had to explain to my current doctor repeatedly that I have no interest in prolonging my life at the expense of always feeling terrible.
satby
@gelfling545: Yeah, I have a friend who has a new, younger doctor who just took her off BP meds for that reason, and her BP was what used to be considered actually “prehypertensive” at 130/80. She says she feels better than she has in years.
WereBear
There’s dozens of studies showing high cholesterol is associated with lower mortality in the elderly. But I don’t think that stops the avalanche of statin prescriptions.
New information indicates that GERD is associated with LOW stomach acid, and steps should be taken to re-adapt the stomach with diet adjustments and probiotics. But that doesn’t stop doctors from reaching for the prescription drugs… to further lower the stomach acid, which is part of the digestive problems, which then results in gut issues and low nutrition.
And the bisphosphonates like Fosamax turn out to destroy women’s bones, not strengthen them. Whoops!
low-tech cyclist
Those are words of wisdom for just about any profession. And I’m gonna steal it for use in my own workplace, which is getting all ‘agile’ and ‘transformational’ while employees’ ability to get the basic job done gets neglected.
With respect to medicine, this reminded me of something Julia Belluz and Sarah Kliff said on Vox the other day in their piece, “No more dieting, and 7 other things we do differently after reporting on health care,” which was that while many types of cancer screening are genuine lifesavers, there are forms of cancer we overdiagnose for at genuinely counterproductive levels. I don’t have time to summarize their chart on breast cancer diagnosis, and words don’t do it justice anyway. Just go there and look at the graph about breast cancer.
MobiusKlein
@Jim: why not have the BP device talk direct? Which frequency. Which patient? Privacy? The integration issues are daunting.
Perhaps the nurse could have a device they carry it communicates with?
tesslibrarian
My grandmother was in her mid-80s when her GP started to put her on blood pressure meds–it was always high when she showed up for her appointment. Eventually, she was on 2, and within a few weeks, she was hospitalized, managed to escape from the hospital, and was found at the corner of a major intersection nearby asking when the next streetcar was scheduled to stop.
My uncles (idiots) were prepared to write her off to dementia and put her in a home, even though she’d been fine just a few months prior. It took my mother flying down (too soon after her hysterectomy to travel, really) to take my grandmother to a gerontologist, who, among other things, discovered she had typically seen her GP at 8:30am appts that involved driving through Atlanta rush hour traffic, so of course her blood pressure was high. They took her off the meds, and she lived independently for another 4 years, when she did start to have health issues at about 89.
Anecdotal, but it’s something I keep in mind, as my grandmother and I have often shared health issues. Also: uncles are idiots.
Fair Economist
@WereBear:
When my husband, who has high cholesterol but is otherwise low cardiac risk, was prescribed statins I took a look at the risk profile and told him not to take them. They are associated with an increase in accident deaths which for a long time was ignored but recently it was found that statins slow reaction times. Oops. Add the risks of liver damage (often reversible) and muscle damage (not reversible) and my mother’s apparent arrhythmias from statins and I told him not to take it.
It is mounted on cinderblocks, so if you can't find a short tank we have room by pulling the block out.aJ R in WV
Lately every professional I’ve seen has taken my blood pressure, dentist, surgeon, family doctor. They all get different numbers, mostly lower than my doctor.
At the family doctor’s office, he has a nurse take weight, pulse, b/p, interview to discover issues the patient wants to discuss.
Then you wait a while, and the doctor takes my b/p again, and for me, it’s always quite a bit lower than when the nurses take it. He uses the old fashioned device with mercury, as opposed to the little electronic gadgets the other health care folks use.
My friend the ER doc won’t take statins, says there’s little correlation with health, and no proven causation at all to go with what correlation there is. His family practice doctor and he argue about it every appointment. My family doc says even if the statin’s effect on cholesterol isn’t important, they have other benefits as well… who to believe?
J R in WV
Lately every professional I’ve seen has taken my blood pressure, dentist, surgeon, family doctor. They all get different numbers, mostly lower than my doctor.
At the family doctor’s office, he has a nurse take weight, pulse, b/p, interview to discover issues the patient wants to discuss.
Then you wait a while, and the doctor takes my b/p again, and for me, it’s always quite a bit lower than when the nurses take it. He uses the old fashioned device with mercury, as opposed to the little electronic gadgets the other health care folks use.
My friend the ER doc won’t take statins, says there’s little correlation with health, and no proven causation at all to go with what correlation there is. His family practice doctor and he argue about it every appointment. My family doc says even if the statin’s effect on cholesterol isn’t important, they have other benefits as well… who to believe?
NotMax
Wondering how much of the supposed gain in productivity can be laid at the feet of any reduction of severe or acute cases receiving primary care in the ER by uninsured procrastinators.
Richard Mayhew
@J R in WV: And that is why knowing the Number Needed to Treat (NNT) is useful:
http://www.thennt.com/nnt/statins-for-heart-disease-prevention-without-prior-heart-disease/
There is some big benefits to rare people for statins, and lots of widespread side-effects that are not as severe.
Richard Mayhew
@NotMax: Given the time of the study and the narrow set of disease categories that they looked at, ACA insurance expansion would not be a significant factor.
boatboy_srq
@MobiusKlein: No small part of it is the lifecycle difference between information technology and medical technology. Medical tech lasts a very long time, sometimes for decades; IT cycles at 5 year increments (for servers) and three year increments or less (for desktops), and even less for smartphones and wireless devices. Getting medical folks to grok that the state-of-the-art computer equipment they bought five years ago is well past its expected lifespan when the medical tech they bought 10-15 years back is still humming along nicely (and still state-of-the-art for that tech) is hard enough. Getting them to retire those devices because they’re not interconnectible, can’t talk to modern information systems, and (all too frequently) represent a significant data security risk if they ever do get connected, is a real PITA. It’s particularly difficult to get folks who are used to HIPAA compliance on their desktops (with all the data security it entails) to understand that their patient data could be compromised by a blood-pressure cuff, MRI or other device too old to meet modern wifi security standards or communicate with a secure network, and would require sending its data in the clear (or at best using compromised algorithms) which exposes both the current reading and the record being updated.
WereBear
I believe this doctor:
Dr. Stuart Graveline, “SpaceDoc” on statins
This particular side effect of statins is most insidious… when I speak of a statin’s degenerative effect on the brain, 99% of the time someone will protest: “They’re old, they have memory problems anyway.”
And that is, excuse me, a stupid way to think.
Roger Moore
@Jim:
And, of course, this is not just inefficient; it also provides another place for errors to creep into the system. For a lot of things, those errors are unimportant or will be caught before they get too far, but it’s kind of silly that we’re using a system that’s less efficient and more error prone.
Eric U.
@tesslibrarian: I have this same problem with my BP, it’s always high when I go to the doctor because I ride my bike to the office. When I say “high,” it’s the infamous “pre-hypertensive” range. Now I’m suffering from white coat syndrome, because I feel like they are jerks to me about it. So I decided to buy a cuff and monitor my own. I didn’t cherry pick the data, just took my BP every day. This was a stressful time since my wife was bed-ridden and in pain and pretty much is a horrible patient. So when I went to the doc, he cherry picked the high days. Can’t win. I’m not taking anything until the data is a lot more conclusive than that. The more I looked into it, the more I realized it’s bordering on witch doctor medicine and they make a lot of assumptions based on some really sketchy criteria.
Roger Moore
@MobiusKlein:
The most obvious approach would be to have the BP cuff talk to the computer by a well-established protocol. If the cuff stays in the same place except for service, there’s no reason to use a wireless protocol at all; you can just connect it to the computer with a USB cable, which would be pretty much unhackable.
Smedley the uncertain
@MobiusKlein: My primary doctor plugs my angiogram leads directly into his laptop which is open to my folder; patient ID assured. Yet, he takes my BP manually with a stethoscope and Sphygmomanometer hanging on the wall and manually enters the data into the PC.
Yet hospitals monitor both data sources remotely and enter the information in their data base. Go figure.
Eric U.
when I bought my BP cuff, I was sure it was USB. Must have looked at too many and gotten mixed up. It remembers your numbers. Just looked on Amazon, and it doesn’t seem like this is a very common feature. I wasn’t going to go through all 270 pages of results though
I was hoping to find a 24 hour monitor that I could afford. I guess all the companies that make them are hooked on insurance payments, because they seem to be very expensive
Wag
@a hip hop artist from Idaho (fka Bella Q):
That was a bad day.
CONGRATULATIONS!
@Riggsveda: I find this mind-boggling, but have seen it far too often to discount. They really don’t wash their hands.
Last FOB I was at, there were a couple of MPs and rows of sinks at the only entrance to the dining hall, and the MPs were posted there 24/7 expressly to insure that every single dumb motherfucker there, be they grunt, contractor, officer or general, washed their goddamn hands before entry. Can’t afford a norovirus outbreak in a combat zone!
Can’t afford one in a hospital or medical complex either, and as a society we really need to start getting serious about sanitation again. When all the antibiotics quit working in a decade, it will be the only thing standing between us and annihilation.
Tripod
@boatboy_srq:
There’s that. And there’s the second and third order costs – server and network spend, additional support staffing, licensing for the application, and an insane quote from Epic for the interface module.
boatboy_srq
@Tripod: Outside the last one, you’re only mentioning costs that other businesses incorporate into normal operating expenses (in no small part because they depreciate their IT equipment in a reasonable amount of time). This is how business works in the ’10s. Nobody likes forking over that much cash – but somehow, hospitals and medical enterprises seem especially allergic because of the disparity in tech aging since they often can’t grasp that the infrastructure they bought in the early 00s is now hopelessly out of date. Your “server and network spend” and “licensing for the application” aren’t significantly different from the rest of the corporate planet; and the staffing, while it does hit the administration GLs, is still a smaller bite than more MDs or RNs and could easily be handled by a consultant firm if the FTE numbers are too high.
piratedan
one other side effect that is never mentioned is that with the ACA passage, there was a boatload of money tossed into the kitty for hospitals to upgrade their internal systems and equipment in order get government grant money in order to modernize and get compliant with more medical standards and practices. A WHOLE bunch of systems and organizations chased that money allowing the systems that they use internally to be upgraded, if not wholly subsidized. Those changes have to have spawned process improvements making your care better and modernizing the process.
Jeffrey Lamkin
Be careful what you wish for. These rises in productivity are happening in classic American fashion–by working the personnel of the hospitals to death, on bare bones staffing schedules, and using wage theft routinely. I know. I work at one.
Morale has never been worse in the American health care system, largely because the ACA put private, for profit insurers largely in charge. The chickens will come home to roost, eventually.
When we’ve taken profit out of the equation, then we can all celebrate productivity increases.
Jeffrey Lamkin
@CONGRATULATIONS!: I”m inside the system, and, believe me, there is a huge push right now on safety, starting with hand washing.
Give us some time.
GHayduke (formerly lojasmo)
We track metrics for dismissals on heart attack and heart failure dismissals (aspirin on dismissal, beta blocker, ACE/ARB etc) and I always joke “thanks obama”…although we have tracked these for many years, it is the PPACA (and linked reimbursement) that has really made us step up our game.
And it’s good for patients.
GHayduke (formerly lojasmo)
@It is mounted on cinderblocks, so if you can’t find a short tank we have room by pulling the block out.aJ R in WV:
1) automated blood pressure cuffs are crap…especailly single readings.
2) This cardiology nurse won’t take a statin unless he has a heart attack.
A guy
If Americans would eat less, work out more and move away from the internet hospitals wouldn’t need to be so efficient. Everybody be honest, raise your hand if you are fat. Mine is down
GHayduke (formerly lojasmo)
@A guy:
Used to be…kind of still am. Probably 20 pounds to go.
I walk at least five miles a day, run three miles most days, lift a couple times a week.
Not too worried about being “fat” actually…and you should not frame it like that, because it makes you sound kind of dickish.
A guy
I don’t care to sound Dickish. American are fat and somebody should tell then.
A guy
You got kids? Do you sound Dickish when you tell them the home works sucks.? America health problems are self inflicted but nobody will own up to that.